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EDITORIAL

What Is Blood and What Is Not? Caring for the Jehovah's Witness Patient Undergoing Cardiac Surgery

From the Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Emory University School of Medicine, Emory Healthcare, Atlanta, Georgia.

Address correspondence and reprint requests to Jerrold H. Levy, MD, Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd., N.E., Atlanta, GA 30322. Address email to jerrold.levy{at}emoryhealthcare.org. Reprints will not be available.

The definition of what blood is has changed throughout history. In ancient Greece, Hippocrates characterized it as one of the four humors, along with yellow bile, black bile, and phlegm. In the 18th century, William Hewson correctly described blood as "spherical red particles that pile up like coins (which are) diluted with serum." Today, with our powerful electron microscopes and other molecular probes, we can see many more "particles" that make up the solution(s) we know as blood. By applying advanced isolation techniques and recombinant technology to these molecules, we are beginning to blur the lines between drug and blood products.

Defining blood takes on a special importance when dealing with the Jehovah's Witness (JW) patient population. Most anesthesiologists are familiar with this group's policy of blood refusal, even at the expense of greater morbidity and mortality. What most clinicians are not aware of, however, is the JW definition of blood. In the year 2000, and again in the year 2004, The Watchtower Bible and Tract Society, the official voice of the religion, defined the "primary components" of blood as red blood cells, white blood cells, platelets, and plasma (1,2). It came as no surprise to the medical community that members were told that transfusion of these specific products was forbidden. What has gone largely unnoticed by many anesthesiologists, on the other hand, is that the acceptance of fractionations of the primary components was left to the individual believer.

Many products commonly used in medical practice fall into the JW category of potentially acceptable blood fractionations. Immunoglobulins, albumin, and purified Factors VIII and IX (called "hemophiliac preparations" by religious leaders) have been available since 1978 to JW followers whose "conscience would permit such." (3). Interestingly, erythropoietin is actually solubilized in a solution that contains human serum albumin.

The key for anesthesiologists, especially cardiac anesthesiologists, is to have a thorough preoperative discussion about what fractions of the primary components are available and which ones the individual JW patient is agreeable to accepting. During the discussion, it may be helpful to know that JW leaders have informed their members that "some protein fractions from plasma do move naturally (from mother to fetus) which may be another consideration when a Christian is deciding (about what fractions to accept)" (4). One could surmise that this opens the door for many isolated protein preparations, such as thrombin concentrates and cryoprecipitate. Unfortunately, most JW patients do not know these options exist, or how they might be beneficial, let alone ask for them.

As well as blood components, it is also necessary for anesthesiologists to discuss blood salvaging measures based on the surgical procedures. JW patients are prohibited from preoperative autologous blood donation and will not allow their blood to be stored in separate containers, regardless of the length of time. However, techniques have been described for both cell saver use and acute normovolemic hemodilution that keep the patient's blood in continuity with the circulation (5,6). In procedures using cardiopulmonary bypass, the use of low-prime circuits and autologous priming has been described and may be beneficial (7). Table 1 summarizes a list of techniques that have reportedly been used to successfully manage JW patients undergoing cardiac surgery.

These patients are hardly a new development. In 1977, Drs. Ott and Cooley (13) reported on 542 cardiovascular operations on JW patients, both with and without cardiopulmonary bypass. Since then, new techniques and preparations have become available that may benefit this patient population. Yet instead of educating each individual patient and allowing them to decide what may be acceptable, many hospitals treat this group collectively according to what they believe is the church's official guidelines, even though advances in component therapy and changes in JW policy have broadened the options available to JW patients.

As cardiac anesthesiologists, it is our job to present these options, and allow the individual patient to decide what is acceptable and what is not. It is only by understanding each believer's own definition of blood that we can provide the best care for JWs undergoing cardiac surgery and other surgical procedures in which there is significant risk for blood loss. Further development of novel strategies, including blood substitutes, recombinant, and transgenic alternatives to blood products, offer additional therapeutic approaches to treat bleeding in this patient population (13–16).

	Footnotes

 
Accepted for publication November 14, 2006.

Reprints will not be available.

	REFERENCES

Top REFERENCES

 

1. Watch Tower Bible and Tract Society. Questions from readers. Watchtower 2000;15:29–31.
2. Watch Tower Bible and Tract Society. Questions from readers. Watchtower 2004;15:22.
3. Watch Tower Bible and Tract Society. Questions from readers. Watchtower 1978;15:30–1.
4. Watch Tower Bible and Tract Society. Questions from readers. Watchtower 1990;1:30–1.
5. Malan TP, Whitmore J, Maddi R. Reoperative cardiac surgery in a Jehovah's Witness: role of continuous cell salvage and in-line reinfusion. J Cardiothorac Anesth 1989;3:211–14.[Medline]
6. Khine HH, Naidu R, Cowell H, MacEwen GD. A method of blood conservation in Jehovah's Witnesses: incirculation diversion and reinfusion. Anesth Analg 1978;57:279–80.[Free Full Text]
7. van Kempen RAB, Gasiorek JM, Bloemendaal K, et al. Low-prime perfusion circuit and autologous priming in CABG surgery on a Jehovah's Witness: a case report. Perfusion 2002;17:69–72.[Abstract/Free Full Text]
8. Jovanovic S, Hansbro SD, Munsch CM, Cross MH. Redo cardiac surgery in a Jehovah's Witness, the importance of a multidisciplinary approach to blood conservation. Perfusion 2000;15:251–5.[Abstract/Free Full Text]
9. Rosengart TK, Helm RE, DeBois WJ, et al. Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah's Witness patients: implications for a "bloodless" surgical technique. J Am Coll Surg 1997;184:618–29.[Web of Science][Medline]
10. Rosengart TK, Helm RE, Klemperer J, et al. Combined aprotinin and erythropoietin use for blood conservation: results with Jehovah's Witnesses. Ann Thorac Surg 1994;58:1397–403.[Abstract]
11. Beholz S, Liu J, Thoelke R, et al. Use of desmopressin and erythropoietin in an anaemic Jehovah's Witness patient with severely impaired coagulation capacity undergoing stentless aortic valve replacement. Perfusion 2001;16:485–9.[Abstract/Free Full Text]
12. Tanaka KA, Waly AA, Cooper WA, Levy JH. Treatment of excessive bleeding in Jehovah's Witness patients after cardiac surgery with recombinant Factor VIIa (Novoseven). Anesthesiology 2003;98:1513–15.[Web of Science][Medline]
13. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. JAMA 1977;238:1256–8.[Abstract/Free Full Text]
14. Levy JH. Hemoglobin-based oxygen-carrying solutions: close but still so far.[comment]. Anesthesiology 2000;92:639–41.[Web of Science][Medline]
15. Levy JH, Despotis GJ, Szlam F, et al. Recombinant human transgenic antithrombin in cardiac surgery: a dose-finding study. Anesthesiology 2002;96:1095–102.[Web of Science][Medline]
16. Levy JH, Fingerhut A, Brott T, et al. Recombinant factor VIIa in patients with coagulopathy secondary to anticoagulant therapy, cirrhosis, or severe traumatic injury: review of safety profile. Transfusion 2006;46:919–33.[Web of Science][Medline]

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This Article Full Text (PDF) CME: Take the course for this article: Management of Coagulopathies in Patients Who Refuse Blood Components Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sniecinski, R. Articles by Levy, J. H. Search for Related Content PubMed PubMed Citation Articles by Sniecinski, R. Articles by Levy, J. H.